Cross-gender Hormone Replacement Therapy

This section of the guide provides information on access to cross-gender Hormone Replacement Therapy (HRT) for trans people. Though not all trans people seek out HRT, for many it is an important aspect of their transition. Making HRT more accessible is integral to advocating for trans clients. This chapter will provide information to guide frontline workers and community organizations in the process of referring trans people to appropriate services and supporting them through the process of accessing hormones. It will also give an overview of different protocols and processes for prescribing hormones and outline some of the barriers that trans people face in Québec when trying to access HRT.

Initiating Cross-Gender Hormone Replacement Therapy

Many health care professionals harbour fears surrounding prescribing hormones to trans people, feeling as though they are not qualified or do not have the proper expertise or training. In fact, any doctor certified to practice medicine in Québec is able to prescribe hormones. People who get hormones by prescription (rather than through friends or the underground market) usually get them in three main ways: from a general practitioner, from a specialist, or from a gender clinic.

General Practitioner (GP): A GP (or family doctor) works with patients with a wide variety of needs and medical conditions. They may work out of a private practice or through a local CLSC. The job of a GP is to look after the overall health of their patients. Many family doctors provide HRT as part of primary care. Whether or not a GP will prescribe hormones to a trans person usually depends on both their comfort level and their knowledge base about trans health issues. If a family doctor is comfortable with providing a prescription for hormones to a trans patient, but is not knowledgeable on the subject, they might agree to do some research, and then prescribe once they are more informed.

Unfortunately, some doctors are uncomfortable providing hormone therapy to trans people under any circumstances, and a person trying to access trans-specific care might have to find a new GP. Organizations that provide services to transgender, transsexual, and/or intersex people often maintain relationships with local doctors who are informed of the health issues surrounding HRT, so if the individual doesn’t have a family doctor already, or if their family doctor is not willing to prescribe, a local organization might be a good starting point. To access information on doctors who prescribe hormones in Québec, contact a member of the Trans Health Network at santetranshealth@gmail.com.

Specialist: Other than GPs, two types of doctors who are qualified and most likely to be willing to prescribe hormones are endocrinologists and gynecologists. For the most part, these specialists require a referral from a general practitioner to book an appointment, but a person can technically self-refer. Some specialists are covered by Québec Medicare. Some specialists will initiate HRT only with a letter from a mental health professional that indicates an official diagnosis of Gender Dysphoria. Often the waiting list to see a specialist is very long.

An endocrinologist is a medical specialist dealing with internal medicine. They have a special understanding of the role of hormones and other biochemical mediators in regulating bodily functions. They are also trained to treat hormone imbalances.

A gynecologist is a medical and surgical specialist concerned with the care of women from pregnancy until after delivery and with the diagnosis and treatment of disorders of the female reproductive tract. A gynecologist will sometimes prescribe and monitor hormones (to non-transsexuals as well as transsexuals), and will also perform hysterectomies and oophorectomies, two procedures desired by some people seeking masculinization and legally required in Québec to change one’s sex designation from female to male.

Gender clinic: A gender clinic is an interdisciplinary specialty clinic usually located within a hospital. In Montréal, there is a gender clinic within the Montréal General Hospital (officially called “The Human Sexuality Unit”). While these clinics do not provide direct access to hormone therapies and surgeries on site, they have the capacity to perform assessments and treatment of concerns relating to gender identity, including counseling, psychotherapy, hormone assessment and monitoring, and documentation for approval of surgeries. Staff at gender clinics will be able to refer those accepted into the program to a GP or specialist who will write the prescription for hormones after certain requirements have been met. The estimated cost of pursuing therapy through the Montréal gender clinic is $3375 per year. This does not include the cost of hormones, surgeries, or electrolysis; it only includes therapy. At the Montréal gender clinic, it takes one to three years to meet requirements to get access to a hormone prescription.

Although the Montréal General’s Human Sexuality Unit offers services to the trans population, it is not completely accessible nor is it realistic in its demands on its trans clients. The therapy required through this program before prescribing hormones can be years in length and cost upwards of $200 per month. Because none of this therapy is covered by RAMQ, many trans people are left struggling to raise the money necessary to obtain the “offcial diagnosis” of Gender Dysphoria that they need to access relevant trans-specific health care.

Due to the cost and duration of this channel, it is inaccessible for much of the trans population. Trans people, as a group, face discrimination in employment, education, and in housing, and as such the majority live at or below the poverty line. This makes paying $200 a month unrealistic for many. Even in the best-case scenario, if a trans person is able to raise the money needed to complete the program, very few doctors are willing to prescribe hormones and the gender clinic does not have doctors on staff to prescribe them.

While for many years, the Human Sexuality Unit was understood to be the only option for trans and gender-variant people to access relevant services and Sex Reassignment Surgery covered by the Quebec government, there are currently many other options. Because procedure at the Human Sexuality Unit does not follow the WPATH Standards of Care or a harm reduction model, the services are often considered out-of-date. Furthermore, due to this program’s prohibitive costs, stringent protocols, and lengthy waits for access to hormones and surgery, many trans people have been seeking out other options. For references to trans-positive mental health professionals, family doctors, and specialists, contact ASTT(e)Q at 514.847.0067. ext. 207.

At gender clinics in general, the common intake procedures involve the trans person answering a host of personal questions, including questions about sexual fantasies, favourite sexual positions, etc., in front of a panel of up to nine people affiliated with the clinic (e.g. doctors, student interns, and researchers).

Protocols and Standards of Care

Health care professionals use a variety of protocols when assessing readiness for HRT. Below is an outline of some of the protocols available, along with brief descriptions of the frameworks on which they are based.

The World Professional Association for Transgender Health (WPATH) Standards of Care

The WPATH Standards of Care are most commonly used among health care providers when prescribing hormones. The WPATH (formerly known as the Harry Benjamin International Gender Dysphoria Association) Standards of Care are put forward by a professional body made up of psychiatrists, endocrinologists, surgeons, and other health care professionals. Some of the topics addressed in the Standards of Care include suggested requirements for HRT, surgery, and post-transition follow-up. WPATH released the 7th version of its Standards of Care in 2011. Many of the revisions are considered to be a vast improvement on the older versions, as the current document leaves room for health care providers to tailor the Standards of Care to their patients’ individual needs.

Up until the 7th version of the Standards of Care was released, one of the suggestions for the initiation of HRT as outlined in the WPATH Standards of Care was the Real Life Experience (RLE). This prerequisite for hormone therapy initiation is based on the belief that in order to be able to make an informed choice about whether or not to transition (change sex), a transsexual person must live in their desired gender role full time. This includes seeking employment or attending school as this gender. For some professionals, only once this criteria has been met will they consider a transsexual ready for medical intervention (hormones, surgery, etc.).

A lot of debate surrounds whether or not the RLE is a necessary and/or ethical requirement for the initiation of HRT for trans people. The RLE is advocated for and practiced by many who follow older versions of the WPATH Standards of Care. According to this model of treatment, once the RLE period is over the person can decide if they would like to begin hormone treatment. The concept behind this belief is that transsexuals need to experience socialization in their chosen gender role in order to have a clearer understanding of the realities of life in that gender. Experience has shown that the RLE seldom changes a person’s mind about transitioning. On the other hand, it does place transsexual people at significant risk. In many cases it is difficult or impossible for a transsexual person to pass unnoticed in the world in their desired gender without the benefit of hormones and/or surgery. Pre-transition transsexuals undertaking RLE are often easily identifiable as trans people, and thus often become targets of hate crimes and discrimination.

There is no scientific evidence that supports the belief that the RLE is beneficial or even necessary to transitioning. In fact, research done on the RLE indicates the contrary. Finally, even the WPATH board has changed opinion on the RLE several times. The 1979 version of the Standards required six months of RLE before a person was permitted to access surgery or hormones, while RLE was dropped completely in the 1981 revision. The 1988 revision reintroduced the RLE as one of the requirements to access HRT. The current edition of the Standards of Care does not suggest the RLE as a prerequisite for HRT at all.

Without scientific basis to prove its usefulness, the RLE is now sometimes used as an indicator of someone being serious about transitioning, but is no longer considered by most professionals, and even the WPATH, to be a required step in this process. Because the RLE can actually place transsexuals at physical and emotional risk, a responsible service provider may conclude that the RLE should remain an optional experience, rather than a requirement, for cross-gender transitions.

It should be noted that the current version of the WPATH Standards of Care leaves a lot of room for a harm-reduction model. The document suggests that health care providers use the Standards of Care guidelines that can be modified depending on the individual needs and life circumstances of the patient. It states: “Clinical departures from the SOC may come about because of a patient’s unique anatomic, social, or psychological situation; an experienced health professional’s evolving method of handling a common situation; a research protocol; lack of resources in various parts of the world; or the need for specific harm reduction strategies.” While ongoing therapy can be an important source of support in a person’s gender transition, trans-positive and -specific mental health care is not always possible, because of financial limitations or geographical location, nor is it always desired by the patient.

Furthermore, the Standards of Care document also recommends a harm-reduction approach applied in circumstances where trans people are using black-market hormones. In outlining the requirements for HRT initiation in trans adults, this particular section indicates that it is acceptable for a doctor to forego the standard requirements “to facilitate the provision of monitored therapy using hormones of known quality, as an alternative to black-market or unsupervised hormone use.”

It is important for all health care providers who are considering prescribing hormones to trans people to read through this document. The WPATH Standards of care can be found at <http://www.wpath.org/ publications_standards.cfm>.

Although the WPATH Standards of Care are the protocols most widely used by health care providers, many clinics and individual doctors prefer to create their own guidelines and assess readiness for HRT using models based in harm reduction, self-determination, and informed consent. Such protocols assume that the individual is best equipped to make decisions about their own body, while providing the tools to ensure that the client has all the necessary information to make an informed decision. The relationship between these kinds of protocols and the WPATH Standards of Care changed when the 7th version of the latter was released in 2011. The new WPATH Standards of Care are more flexible, and they support the initiatives of individual clinics and doctors who alter and tailor the document to suit the needs of their clients.

Alternative Protocols

Both the Tom Waddell and Callen-Lorde Protocols are guidelines for health care providers and are based on the principles of harm reduction and informed consent. These guidelines do not determine who is eligible for treatment; they are working protocols designed to provide care to people who already self-identify as transgender and contain the assumption that people know what is best for their own bodies. These two protocols are the most commonly used by health care professionals and clinics working within a harm-reduction framework. Other protocols and standards, developed by individual doctors or clinics, are also available. A comprehensive list of these protocols can be found at <http://www.santetranshealth.org>.

Initiating hormone therapies for trans people within a harm-reduction framework is one way of advocating for trans people, who experience multiple barriers to access to adequate and respectful health care. Doing so acknowledges the ways in which the systems in place to access trans-specific health care services do not take into account many of the realities that trans people face every day.

Keep in mind that the 7th version of the WPATH Standards of Care, which are internationally recognized as a document assembled based on the experience of practitioners worldwide, now supports the use of harm-reduction models of care. Trans people have pushed for harm-reduction models of care to be recognized as a legitimate practice when prescribing hormones for decades, and the importance of the inclusion of that perspective is groundbreaking.

Assessing Readiness for Hormone Replacement Therapy

An ethical approach to determining whether HRT is suitable for someone will necessarily include enhancing patient knowledge and emphasizing patient self-determination. As a health care practitioner, you will undoubtedly come into contact with trans people who want to receive hormone therapy and have differing levels of information regarding the risks and benefits of this treatment. Therefore it is essential that you can provide them with accurate information. They need to be aware of possible side effects as well as the consequences of short- and long-term hormone use. Someone who has accurate information about the effects and risks of HRT, as well as the mental capacity to make a decision, will be the best judge of whether or not they should undergo this therapy. Once your client has made the decision to begin hormone therapy, you may wish to have them sign a consent form stating that they are aware of the risks and permanent or temporary changes that might occur should they begin treatment, as well as to confirm their desire to begin treatment.

Many trans people choose not to—or are unable to—access HRT through a doctor, with a prescription. As a result, people access hormones on the underground market, over the internet, through a dealer, or from a friend who has a prescription. Often, when trans people access hormones without a prescription, the brand or kind of hormones they are taking are inconsistent. They also might not have information on the proper dosage or how to administer the hormones.

Advocating for trans people who are taking hormones without a prescription includes the acknowledgment that people make choices in their lives that make the most sense for them. People decide not to access hormones through legal channels for a variety of reasons: many trans people access hormones through the underground market because they have had bad experiences accessing health care in the past, or because they do not have status in Canada, and therefore cannot access health care services. Please consider and be sensitive to the individual journeys of the trans patients you encounter when you are discussing HRT with them.

Liability

The use of an informed consent form, baseline tests and proper monitoring of patients on HRT are the best protection you have against liability.

Informed consent: Informed consent in the context a patient who wishes to undergo HRT involves communicating to them the risks and side effects associated with hormone therapy and making sure the patient understands these risks. A frank discussion with your patient can help determine what they already know about hormones and what information you can offer. Physicians must be able to offer accurate and complete information regarding risks and side effects of hormones to patients. Therefore, the more you as a doctor know about hormones, the better you can inform your patient and thereby reduce your liability. The more a patient knows about hormones, the better equipped they are to make good decisions about their transition and be happy with the results. The consent form must state clearly that the patient has been informed of the risks associated with HRT, and that they are willingly receiving hormone treatment. It must also state that the medical practitioner is not responsible for this decision but that they will, however, ensure the best care possible through the transitional process and follow-up.

Sample informed consent forms can be found at <http://www.santetranshealth.org>.

Baseline tests: All patients who are about to begin HRT should be given a series of baseline tests, which will be important in determining hormone dosage and useful in future monitoring. Below are the baseline tests suggested prior to commencement of HRT. It is recommended that the tests be repeated two months after starting or increasing the dosage and every six months after establishing a stable dosage.

Baseline tests for patients planning to begin HRT:

CBC with differential

liver panel

renal panel

glucose

hepatitis B total core ab

hepatitis C ab

VDRL (or RPR)

lipid profile

prolactin level

urine GC

chlamydia

HIV

surface antigen and antibody

testosterone level

estradiol

A more in-depth list of baseline tests and a detailed description of recommended guidelines for HRT in trans adults can be found at <http://transhealth.vch.ca/resources/library/tcpdocs/guidelines-endocrine.pdf>.

Monitoring: After prescribing the hormones, the doctor must be able to adequately monitor their patient. If they are uncomfortable with this type of monitoring, they can provide a referral to another health care provider, such as an endocrinologist. If you are a doctor reading this guide, please keep in mind that you already have more information and training on this subject than many other doctors. therefore, referring a trans patient somewhere else is not always the best solution. Please consider talking with colleagues about their experiences working with trans people before making referrals. ASTT(e)Q has access to a database of trans-specific and trans-positive health care and social service providers. Contact us if you are looking for a trans-positive doctor with specific skills and training.

Hormone Regimens

Trans men on HRT take testosterone. This is most commonly administered by intramuscular or subcutaneous injection, but is available in transdermal (patch or gel) or oral (pill) forms.

Trans women on HRT usually follow a regimen of taking both anti-androgens, to suppress the production of testosterone in the body, and estrogen, to induce typically female characteristics. Anti-androgens are generally administered orally (pills). Estrogen is available in oral (pill) and transdermal (patch, gel, cream) form. While injectable estrogen is not available by prescription in Canada, it can be found on the black market. A third hormone, progesterone, is linked directly to the reproductive cycle in people assigned female at birth and is not produced in those who were assigned male at birth. It is not necessarily prescribed as part of a hormone therapy regimen for male-to-female trans people.

Permanent and Reversible Changes

Expected Effects of Testosterone

Permanent changes include:

Lowering of voice

Increase and development of facial and body hair

Possibility of sterility

Possibility of permanent hair loss

Increase in size of the clitoris

Reversible changes include

Loss of menstruations

A redistribution of body fat into a typical male pattern away from hips and to the middle

Increase in muscle mass

Thicker, oilier skin

Development of acne problems

Increase in libido

Mood changes

* These changes should revert if HRT is stopped.

Expected Effects of Estrogen

Permanent changes include:

Breast tissue development

Possibility of sterility

Reversible changes include:

Loss of erections (spontaneous and morning) as well as a difficulty to maintain a firm enough erection for penetration

A decrease in acne

Diminished or slowed balding

Softer skin

Less noticeable body hair growth

Less prominent beard growth

Decrease in abdomen fat and redistribution to the buttocks and thighs

Change in libido/decreased sex drive

Mood changes

*These changes should revert if HRT is stopped.

The amount of time it takes for certain changes to become perceptible varies from one person to another. As a general rule, people experience the majority of changes during the first two years of their hormonal transition; however, some big changes may occur after that point. The patient is unlikely to experience any growth of the musculature unless they have not yet finished puberty. Once their body has stopped growing, their bone structure will no longer change.

Many trans people initiate HRT and continue to take hormones for the rest of their lives. Some, on the other hand, choose to take hormones only until they achieve the desired changes. Everyone’s decision is legitimate, and it is important to continue monitoring your patient/client’s baseline levels even if they decide to stop HRT.

Referral Letters

Referral letters written by mental health professional are often necessary to initiate cross-gender HRT. As previously mentioned, protocols based in a harm reduction philosophy generally don’t require a referral letter from a mental health professional. Many doctors or clinics using the WPATH Standards will request one before initiating hormones. Referral letters are also required for Sex Reassignment Surgery, and are written in the same fashion.

While it is necessary to include the person’s legal name and birth sex in a referral letter, if they do not identify with either of these, then they need only be included in the letter as a matter of fact. Simply indicate legal name, the actual name, and then write the letter using the actual name and actual pronouns used by the patient (e.g. “This letter is with regards to Alice Cheng [legal name David Cheng]. She is a transsexual woman who is legally male.”).

This referral should be written on official letterhead and should include your name and contact information. Therapists, counselors, sexologists, psychologists, and psychiatrists can all write referral letters if they encounter individuals wishing to access hormones or surgery. However, some surgeons or doctors may have more specific requirements for referral letters, for example, they may require a letter from a psychiatrist who specializes in gender identity. It is important to double-check the specific requirements of each doctor before sending your patient to them. According to the WPATH Standards of Care, a letter of reference to initiate HRT must be written by a mental health professional, and must include the following elements:

The patient’s general identifying characteristics

Results of the client’s psychosocial assessment, including any diagnoses

The duration of their professional relationship including the type of psychotherapy or evaluation that the patient underwent

The eligibility criteria that have been met and the mental health professional’s rationale for HRT or surgery

A statement about the fact that informed consent has been obtained from the patient

A statement that the referring health professional is available for coordination of care and welcomes a phone call to establish this

Minors, Hormone Therapy, and Hormone Blockers

Under Québec law, minors younger than fourteen years old cannot consent to care on their own. When a person reaches the age of fourteen, they are then able to make many decisions about their health without requiring the consent of their parents or guardians. Minors aged fourteen years or older are generally considered capable of making decisions about their sexual health, and their confidentiality is assured in the same way as it would be for an adult except when the security or development of the teen is considered to be at risk. Minors fourteen years and older will, however, require the consent of their parents or guardian for medical treatments that pose serious risks to their health or could have grave and permanent eﬀects.

At this time, there are no examples of court cases in Québec or the rest of Canada involving minors trying to access cross-gender Hormone Replacement therapy or hormone blockers. If such a case did come before a Québec court, the judge would need to take into account the best interests of the minor, both the minor’s and their guardian’s wishes, and the opinions of experts. For more inforation on the laws surrounding consent to care, please visit <http://www.educaloi.qc.ca/en/loi/health_care_users_and_professionals>.

Some doctors prefer to administer hormone blockers to trans youth, as opposed to initiating HRT at such a young age. this alternative prevents the onset of puberty, and when and if the patient wants to start hormones, that process can be initiated afterwards. There are many advantages to preventing puberty as an initial intervention in youth on the brink of developing undesired secondary-sex characteristics. It makes an eventual transition much easier and less costly. For example, a regimen of anti-androgens from pre-puberty might preclude the need for electrolysis for someone who is seeking a feminine appearance, just as the prevention of breast development might preclude the need for chest reconstruction surgery later on for someone who is seeking a masculine appearance. Another benefit is that there are fewer permanent effects. In the event that a youth changes their mind, the treatment can be stopped, and the patient will experience the normal changes of puberty for their birth sex.

Most obviously and perhaps most importantly, there are the enormous psychological benefits that come from living in one’s preferred gender. Finally, it is beneficial for youth to receive support and validation from the adults in their life through their decision to transition. More information on HRT in young adults can be found at <http://transhealth.vch.ca/resources/library/tcpdocs/guidelines-adolescent.pdf>.

Refugees and Access to Hormone Replacement Therapy

Refugees can be covered for access to general practitioners and doctors in the public system to prescribe hormones, but do not have access to the Québec Prescription Drug Insurance Plan, which might cover some of the costs of the hormones. If the doctor is willing to advocate for their patient, hormones can be covered through the Interim Federal Health Program. The doctor following the patient would have to give an offcial diagnosis of Gender Dysphoria, and explain why and how Hormone Replacement Therapy is an “essential service.” The prescribing doctor must have prior approval, by filling out the appropriate claims form, which can be found on the Medavie-Bluecross website, at <https://www.medavie.bluecross.ca>.

For a list of providers who are registered with the Interim Federal Health Program, visit <http://www.ifhp- pfsi.ca>.

Depression and Hormone Replacement Therapy

Transitioning can be a difficult time for anyone, therefore it is normal that people undergo a wide variety of emotions throughout the process. The wait for HRT to begin can be a difficult and depressing time for transsexuals, as a desire or need for their bodies to reflect their inside may become incessant. This may not be a representation of their general emotional disposition. the prescription then can reduce this anxiety and offer them the feeling that they have started their transition in a concrete way. For others, their depression may be rooted in the difficulties or obstacles faced by those wanting to transition. In those cases it is necessary to gauge what kind of effect transitioning will have on their well-being. Transitioning will not be a miraculous problem solver for the rest of your patient’s life. It will however, offer them some emotional release that might allow them to better handle and tackle the other problems. It is important to remember that hormonal transition does bring some additional stresses. For some there may be problems with employment or with family. Therefore it can be good to refer the person to some other support systems in order to help them deal with the psycho- social effects of transitioning.

While there have been some reports of depression specifically due to estrogen therapy, this in itself should not be a reason to counter indicate hormones. A patient’s prior history of depression should always be taken into consideration. In some cases it may be necessary to prescribe an anti-depressant or to modify their hormone dosage.